VBA-26-0967a-ARE.pdf

SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS

OMB Control Number: 2900-0821 Respondent Burden: 1 hour Expiration Date: 11/30/2021

VA FORM

NOV 2018 26-0967a PAGE 1

(1) Describe how the new assistive technology is innovative:

IMPORTANT: Applicants for SAH Assistive technology grants must provide responses addressing the six criteria items shown below.

NOTE: If additional space is needed please attach separate sheet(s) and indicate item number with response.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.

RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes collection of this information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

SUPERSEDES VA FORM 26-0967a, DEC 2015, WHICH WILL NOT BE USED.

www.reginfo.gov/public/do/PRAMain

PAGE 2 VA FORM 26-0967a, NOV 2018

SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued)

(2) Explain how the new assistive technology will meet a specific, unmet need among eligible individuals:

PAGE 3 VA FORM 26-0967a, NOV 2018

(3) Explain how the new assistive technology is specifically designed to promote the ability of eligible individuals to live more independently:

PAGE 4 VA FORM 26-0967a, NOV 2018

(4) Describe the new assistive technology's concept, size and scope:

PAGE 5 VA FORM 26-0967a, NOV 2018

(5) Describe the implementation plan with major milestones for bringing the new assistive technology into production and to the market.

(Note - The milestones must be meaningful and achieveable within a specific timeframe):

PAGE 6 VA FORM 26-0967a, NOV 2018

(6) Explain what uniquely positions the technology grant applicant in the marketplace.

(Note - This can include a focus on the characteristics such as the economic reliability of the technology grant applicant, the technology grant applicant's status as a minority or veteran-owned business, or other characteristics that the technology grant applicant wants to include to show how it will help protect the interests of, or further the mission of the Department of Veterans Affairs (VA)):

SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

OMB Control Number: 2900-0821 Respondent Burden: 1 hour Expiration Date: 11/30/2021 OMB Control Number 2900-XXXX, Respondent Burden: 1 hour, Expiration Date: XXXXXXX OMB Control Number 2900-XXXX, Respondent Burden: 1 hour, Expiration Date: XXXXXXX

VA FORM

NOV 2018

26-0967a

(1) Describe how the new assistive technology is innovative:

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

IMPORTANT: Applicants for SAH Assistive technology grants must provide responses addressing the six criteria items shown below.

This certification is required by the regulations implementing XXXXXXX This certification is required by the regulations implementing XXXXXXX ..\logos\FORMLOGO.jpg Department of Veterans Affairs Logo Department of Veterans Affairs Logo NOTE: If additional space is needed please attach separate sheet(s) and indicate item number with response.

This certification is required by the regulations implementing XXXXXXX This certification is required by the regulations implementing XXXXXXX PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.

RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes collection of this information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant.

SUPERSEDES VA FORM 26-0967a, DEC 2015, WHICH WILL NOT BE USED.

VA FORM 26-0967a, NOV 2018 SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

(2) Explain how the new assistive technology will meet a specific, unmet need among eligible individuals:

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

VA FORM 26-0967a, NOV 2018 SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

(3) Explain how the new assistive technology is specifically designed to promote the ability of eligible individuals to live more independently:

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

VA FORM 26-0967a, NOV 2018 SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

(4) Describe the new assistive technology's concept, size and scope:

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

VA FORM 26-0967a, NOV 2018 SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

(5) Describe the implementation plan with major milestones for bringing the new assistive technology into production and to the market.

(Note - The milestones must be meaningful and achieveable within a specific timeframe):

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

VA FORM 26-0967a, NOV 2018 SCORING CRITERIA FOR SAH ASSISTIVE TECHNOLOGY GRANTS (Continued) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

(6) Explain what uniquely positions the technology grant applicant in the marketplace.

(Note - This can include a focus on the characteristics such as the economic reliability of the technology grant applicant, the technology grant applicant's status as a minority or veteran-owned business, or other characteristics that the technology grant applicant wants to include to show how it will help protect the interests of, or further the mission of the Department of Veterans Affairs (VA)):

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

M. Wiley 9-28-15

VBA

N. Kessinger Scoring Criteria for SAH Assistive Technology Grants 9-15